Components and Outcomes in Under- and Postgraduate Medical Education to Prepare for the Delivery of Integrated Care for the Elderly: A Scoping Review

Introduction: The ageing society requires physicians who can deliver integrated care, but it is unclear how they should be prepared for doing so. This scoping review aims to create an overview of educational programmes that prepare (future) physicians to deliver integrated care while addressing components and outcomes of the interventions. Method: We included papers from five databases that contained: (1) integrated care (2) education programme (3) medical students (4) elderly, or synonyms. We divided the WHO definition of integrated care into ten components for the concept of ‘integrated care’. Data were collected with a charting template, and template analysis was used to formulate themes. Results: We found 17 educational programmes in different learning settings. All programmes addressed several components of the WHO definition. The programmes primarily focused on care for individual patients (micro-level), and the outcomes suggested that experiencing the complexity of care is key. Conclusion: This review revealed the limited evidence on educational programmes about integrated care for the elderly. Our findings suggest that educational programmes on integrated care should not be limited to the micro-level, and that students should obtain adaptive expertise by experiencing complexity. Future research should contain an explicit description and definition of integrated care.


INTRODUCTION
Following in the wake of healthcare, medical education is itself going through a transition because of the ageing society, which is associated with the rise of chronic diseases and multimorbidity [1][2][3][4][5]. Policy papers on medical education, therefore, indicate what qualities (future) physicians should have to prepare for this transition and emphasise the need for learning integrated care [6,7] without, however, providing information on how integrated care should be taught to (future) physicians.
The elderly currently receive care in a fragmented healthcare system that is primarily designed for providing mono-disciplinary care [3]. Consequently, relevant health issues are not consistently recognised, resulting in high risk of complications, rising healthcare costs, and (frail) elderly not experiencing their healthcare as a cohesive continuum [3,[8][9][10][11]. To address this mismatch in the needs of the elderly and the current care provided, integrated care initiatives and evidence are on the rise [9,[12][13][14][15]. For the provision of integrated care, healthcare workers need to be skilled to work within the context of integrated care and capable of coordinating complex care [2][3][4]. To ensure greater collaboration within the healthcare sector [16], therefore, programmes were developed that focus on interprofessional learning, i.e. learning from and with different professionals in health and social care. Although interprofessional collaboration contributes to better care integration, it does not encompass the whole concept of integrated care [17]. Interprofessional learning focuses on better collaboration, but other essential components of integrated care such as finance, prevention, and management are not entirely addressed.
Because a single unifying and accepted definition of integrated care is lacking, educational programmes on this topic are not easily found [14]. The concept is multifaceted and can be approached from different perspectives, complicating the search for such programmes [18]. The explanation for this difficulty goes back twenty years to when the concept of integrated care emerged as a counterreaction to fragmented care [19]. From the perspectives of patients, funders, and healthcare professionals, amongst others, initiatives on integrated care arose, and integrated care, therefore, is subject to different perspectives and terminologies such as 'comprehensive care' or 'coordinated care' [18][19][20]. In addition, numerous frameworks for integration have been described [12,14]. Integration can occur at different levels: the micro-level (individual patient), meso-level (organisational/social context), and macro-level (population) of integrated care. Alternatively, integration is possible in different directions, for example, horizontally (e.g. social and health services) or vertically (disease-based) [12,14,21,22]. This diversity of definitions, perspectives, and frameworks makes research and comparison of integrated care challenging [18,19]. Overviews of integrated care exist for practice. The World Health Organization (WHO), for example, published a document that focuses on integrated care for older people [3], compiled a framework including an elaborated strategy [10], and the WHO Regional Office for Europe has set out an overview of the diverse concepts and models for integrated care [12]. For medical education, such overviews of integrated care do not exist, and this, together with the multifaceted nature of the concept, makes finding and comparing educational programmes quite a challenge.
In order to unite practice, medical education, and the needs of elderly patients, it is necessary to clarify what education on integrated care should entail. Along with practice, education on this topic will develop, and initiatives may already have emerged. It remains unclear whether such educational programmes exist, and if so, on the basis of which theoretical framework they operate and what education these programmes provide. Therefore, this review aims to create an overview of educational programmes, the components they teach, and their outcomes regarding teaching integrated care for elderly patients to undergraduate medical students and postgraduate trainees (physicians pursuing further clinical training to become medical specialists). In this way, this review hopes to contribute to making the necessary transition in medical education, clarify knowledge gaps, and inspire future medical education on integrated care for the elderly.

METHODS
We chose to perform a scoping review as this method is suitable for mapping a broad topic, identifying knowledge gaps, and starting future research [23][24][25]. As a guide, we used 'The Joanna Briggs Institute (JBI) Manual for Evidence Synthesis', based on the frameworks of Arksey and O'Malley [24] and Levac et al. [25], and 'the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)' [23,26]. The scoping review protocol was registered at the Open Science Framework (OSF) [27].

SEARCH STRATEGY
With the help of a librarian, we developed a search strategy by dividing the research question into four concepts: 1. Integrated care and its synonyms 2. Elderly and its synonyms 3. Learning and its synonyms 4. Students/trainees, and their synonyms.
For concept 2, we adapted the search string for geriatric people published by van de Glind et al.. To adapt the concept from geriatric to elderly people in general, we replaced disease-specific components, such as 'Alzheimer's', with broader components, such as 'comorbidity' and added ages, such as '70 years' [28].
Concepts 3 and 4 were combined with [AND] to avoid papers about patient learning. We combined these concepts in the following Boolean search: (Concept 1 AND Concept 2 AND ((Concept 3 AND 4)). In April 2021, we adapted the final search string to PubMed, Embase, PsycINFO, ERIC, and Web of Science databases (see Appendix 1 for PubMed search string, the remaining search strings can be found in the review protocol at OSF). We searched these databases for English publications, including papers from 2000 onwards because integrated care had been upcoming since the end of the 1990s [20,29,30].

SELECTION CRITERIA
The included publications had to describe an educational programme for medical students or postgraduate trainees, in which they learned to provide or gained insight into integrated care for the elderly. For this scoping review, we defined the elderly as 65 years and older. We concluded that the health system-based definition of integrated care, documented in the overview of integrated care models by the WHO Regional Office for Europe, best fitted the purposes of our review (Box 1) [12]. The first screening showed that none of the full-text papers met the full WHO definition. Therefore, we divided the definition into ten components to determine essential components for this review (Box 1).
In order not to exclude too many papers based on their abstracts, we decided that at least two out of the ten WHO components should occur during the abstract screening process. During the full-text selection, the review team discussed that all papers should comply with educational programmes targeting component I. We decided that the remaining components were desirable but not essential for selection. We chose these four mandatory components because they are within the sphere of influence of (future) physicians. Components such as VIII. feedback loops are more challenging for medical students or trainees to influence as they are not responsible and sometimes not even included in the evaluation of care during their internships.
Interprofessional collaboration, as mentioned earlier, is an important component to ensure greater collaboration within the healthcare sector [16], making IV. multidisciplinary team essential. We defined 'multidisciplinary team' as generalists and specialists who collaborate together in health and social care, as mentioned by the WHO in their report as a key factor for implementing integrated care [12]. Currently, for multidisciplinary collaboration, the term interprofessional collaborations (IPC) and intraprofessional collaboration (IntraPC) are also used. IPC means health professionals with different backgrounds collaborating to deliver high-quality care within health and social care [31,32]. IntraPC is defined as health professionals with the same background collaborating to provide care [32]. For this review, we included papers that involved multidisciplinary, interprofessional or intraprofessional collaboration with respect to health and social care.

SELECTION
The review team MW, NS, CF, and DA screened 6,936 titles and abstracts using Rayyan [33]. At least two researchers screened every abstract. The abstract screening resulted in 30 papers for full-text reading. During full-text reading, DA and MW scored every paper on the presence of the WHO components (Box 1). These WHO components had to be reflected as an intention, learning objective, outcome, or element of the described educational programme. If the researchers intended to develop an educational programme for students to become more patient-centred, for example, we scored that component I. was present.
Ten full-text articles and six conference abstracts met the inclusion criteria. The references in these articles were screened in the same way as above, resulting in one additional paper [34]. During inclusion, the review team discussed disagreements. The Prisma flow diagram shows an overview of the selection process ( Figure 1). Box 1 Health system-based definition of integrated care as used by the World Health Organization (WHO) Regional Office for Europe (2016) [4,12] Integrated health services delivery is defined as an approach to strengthen I. people-centered* health systems   Two students from each profession with a target total of six to 12 students in medicine, nursing, physical therapy, physician assistants, pharmacy, and social work.

CONTENT AND SETTING OF THE EDUCATIONAL PROGRAMMES
We subsequently divided the programmes according to their learning settings, i.e. classroom-based, workplacebased, or a mix of both (Table 1). Six programmes had a classroom-based setting [34,37,39,40,47,48]. These programmes varied from interactive seminars based on a clinical case [34,40], a workshop based on a clinical case [37], an application of a web-based tool to manage care on a population level [47], a quality improvement project [39], and a scenario play [48].
The remaining 11 papers described workplacebased programmes. One described a non-traditional longitudinal interdisciplinary clerkship (LIC) incorporating ambulatory care within longitudinal education [42]. Another complemented regular resident rotations with six longitudinal interprofessional curriculum components taught over two years [51]. Other activities included home visits [43,46], joint primary and secondary care clinics [50], ward observations [41], a studentled clinic for recently discharged elderly [52], and an interprofessional student team examining one patient's care and discharge [49]. Lastly, these papers described students or residents paired with elderly persons to provide care [44] or observe their health needs [38,45].
Four of these workplace-based programmes also used teaching activities in a classroom-based setting [38,41,43,51]. For example, students completed a foundational curriculum, after which they continued with home visits to patients [38].

Multidisciplinary setting
All the educational programmes addressed component IV. ('multidisciplinary team'). In eight programmes, the participants participated in teams of students from different professions in healthcare [37-39, 47, 49, 51-53] of which seven programmes included students from social work [38,39,47,49,[51][52][53]. In two papers, participants participated in a multidisciplinary team that was not made up exclusively of learners but also included working professionals in health and social care [40,46]. In three programmes, students received supervision or learned from an interprofessional team of healthcare professionals [34,44,45]. One programme had an intraprofessional learning setting [50], and in one programme, participants received supervision from different medical specialists [42]. Another paper described an interactive session with other healthcare professionals [41], and the last programme described a simulation of a patient who visits multiple health and social care workers [48]. Three programmes featured social care without interaction with a social care worker [34,37,48], and five programmes did not mention social care [41,42,44,45,50].

EDUCATIONAL THEORIES AND CONCEPTS
Five papers mentioned an educational or theoretical concept on which their programme was based. One paper described the concept of situated learning, in which learning requires interaction and collaboration [52]. The second paper described a productive struggle to ensure students' understanding of the complexity of care experienced by patients [48]. The third paper mentioned the pedagogical guideline of problem-solving, in which the students were encouraged to reflect on their actions concerning the actions of other professionals [51]. Another paper described the Leicester Model of Interprofessional Education, which taught students to value teamwork [49]. Finally, the last paper based their programme on problem-based learning, which stimulates creative solution finding and teaches students how to cope with complex problems on a population level [47].

THE RELEVANCE FOR DEVELOPING THE EDUCATIONAL PROGRAMME
Thirteen papers mentioned the relevance of developing education on providing care for the elderly. The relevance items mentioned were the ageing society, the increasing complexity of care demands, and the shortage of geriatricians [34, 37-41, 43-45, 47, 48, 51, 52]. Four papers, however, did not motivate why they taught (a component of) integrated care [42,46,49,50].

COMPONENTS OF INTEGRATED CARE
Based on the inclusion criteria, all programmes contained the following components (Box 1): I. people-centred II. multidimensional needs III. multidisciplinary team IV. across settings and levels.
Although we searched for elements of the concept of integrated care, only two papers mentioned integrated care as a learning objective, but they did not define the concept of integrated care [48,50]. Table 2 [34,40,45,47,51,52], which were both taught in six programmes. Two programmes taught Component VII. ('feedback loops'), which was, therefore, the least taught component [39,47].

Levels of integrated care
As explained previously, integrated care can be considered at micro-, meso-and macro-levels. Except for the paper by Xakellis and Robinson, all programmes focused on the micro-level of integrated care [34,[37][38][39][40][41][42][43][44][45][46][48][49][50][51][52]. Within the programmes focusing on the microlevel, four programmes incorporated the meso-level [34,44,48,49], four the macro-level [39][40][41]51], and two incorporated the meso-and the macro-levels [37,38]. For example, Balogun et al. taught students about the collaboration and financing of different healthcare organisations in the preparation of the workshop [37]. The programme described by Xakellis and Robinson is unique as its focus is primarily on the macro-level, with students being challanged to allocate disease prevention funds to average and seriously ill elderly. The students also learned to think on a meso-level by devising an organisational strategy [47].

OUTCOMES
The authors evaluated their programmes to a greater or lesser extent. Some papers did not specify their evaluation methods [42,45,47], while others provided a preliminary evaluation [40], and evaluations varied from detailed to short descriptions in the remaining papers [34, 37-39, 41, 43, 44, 46, 48-52]. For clarity, we divided the heterogenous evaluation outcomes into the following categories: feedback on the programme, learning outcomes, key factors for learning, and challenges.
Students were positive about the longitudinal mentorship and their progress in skills [42], discussions with patients about care settings [41], interactive formats [34,39], the flexibility of self-directed learning [49], clinical experience [39,45,46], contacts with patients and family caregivers in a non-regulated environment without time pressure [46], quality improvement projects, and the instructor preparation for the programme [39]. Students indicated that clarification of the levels of care was helpful, for example, with a pocket card [41]. Students suggested that the programme could be improved in terms of the level of involvement of other professions [37,52], the timing [34], and the effectiveness [52].
Educators were positive [46,52] and appreciated students' input on the ward [49]. One educator, for example, was pleased because the students had prevented a discharge from failing [49]. For improvement, educators would like to be better trained in providing interprofessional education [52].
Patients were also positive [45,50], appreciating, for example, the interaction with students [45] and the referrals by students to other health services [44,52].

Learning outcomes
The learning outcomes varied. Firstly, there were learning outcomes focusing on the WHO components of integrated care ( Table 2). In addition, surveys showed enhanced student attitudes and self-efficacy in caring for the elderly in different settings [39,41]. Students reported more awareness of the impact of policy on daily practice [49], improved communication [37], and an enhanced understanding of social and environmental aspects of healthcare [46]. Xakellis and Robinson hypothesised that the participating students experienced the clinical and financial sides of healthcare and indicated that the small sample of patients in their teaching could have contributed to providing an accessible way of applying care strategies at the population level to improve individual patient care [47]. Qualitative analyses from Yang et al. showed that students experienced the complexity of care [48]. Lastly, students indicated they had to use their sense of responsibility [42,49,51] and reported a willingness to focus more on the patient's perspective [34,37,39,48,49].

Key factors for learning
Ten papers suggested factors that contributed to the students' learning process [34,37,41,42,46,[48][49][50]52]. Three papers described that observing and experiencing care outside the hospital helped to clarify the different levels of care [41], prevent deterioration [46], and take responsibility [42]. Experiencing care through simulation of [34,37,48] or interaction with patients [49,52] helped students to gain insight into the patients' perspective, among other things. Participating in joint clinics contributed to better collaboration between the different levels of care [50]. Da Motta and Pacheco added that by offering complexity of elderly care to a team of students from different disciplines, students had to appeal to each other's expertise, which taught them to work together in a cooperative way [51]. Yang et al. suggested that complexity as part of their scenario play allowed students to encounter the patients' experience. The struggle with the patients' care navigation provided a better understanding of integrated care, which stimulated the students' critical self-reflection, allowing them to better empathise with patients [48]. These results suggest that complexity as an educational element and experiencing patients' care navigation contributed to the students' learning process.

DISCUSSION
To the best of our knowledge, this scoping review is the first to outline published papers on teaching integrated care for the elderly and its challenges and key factors for learning. The 17 selected papers described various educational programmes in classroom-based, workplace-based or a mix of both settings and had various educational theories or concepts as their foundation. None of the papers mentioned a specific definition of integrated care.
All articles described similar challenges for developing their education programme, namely the ageing society and the increasing complexity of care. Integrated care is put forward as a possible solution to these challenges. Considering the definition we used, i.e. the WHO definition for integrated care (Box 1), we noticed that -spread over the papers -all ten components were reflected in the educational programmes to a greater or lesser extent. It is noticeable that, in addition to the four components used for inclusion, only VI. ('effectively managed care'), was frequently addressed. The five remaining components of the WHO definition, in contrast, appeared in less than half the programmes. The included programmes did not have integrated care as such as their starting-point, but had the challenges and complexities of the ageing society as their foundation, which may be the reason why a definition of integrated care was not used. Based on our research, we cannot clarify why certain components of the WHO definition recurred less frequently.
As described in the introduction, learning to participate in a multidisciplinary team is essential in integrated care. Also, a previous literature review on educational needs for educating nurses in medical education suggests that interprofessional learning is a crucial component in learning integrated care [54]. Therefore, component IV. ('multidisciplinary team') was mandatory for inclusion. Our results showed that students emphasized the need for interprofessional collaboration [37,52], and that interprofessional learning improved collaboration [50,51]. The educational programmes found implemented component IV. ('multidisciplinary') team differently. Two programmes addressed intraprofessional learning [42,50], and the remaining programmes included interprofessional learning [34, 37-41, 44-49, 51-53]. Five programmes did not address social care [41,42,44,45,50], which is understandable in the case of Imam, T., et al. and Meah, Y. S., et al. given that these programmes were set up as intraprofessional learning programmes within the medical profession [42,50]. The connection with social care is important within interprofessional education [31]. Therefore, it is notable that three interprofessional learning programmes did not address social care [41,44,45], and three other programmes only mentioned social care without involving social caregivers [34,37,48]. Also, when we look at research about social care within integrated care and the definition of integrated care (i.e. component III. ('multidimensional needs'), social care is important in integrated care [12,55]. Therefore, we recommend that educational programmes towards integrated care should pay attention to multidisciplinary collaboration, including social care.
In addition to the WHO components, we examined the different levels of integrated care that were taught. The main focus of the programmes was the micro-level of integrated care with extensions to the other two levels. This finding is consistent with the integrated care approaches for the elderly in practice, which focus mainly on the micro-level [56]. Nevertheless, 11 of the 17 educational programmes did introduce students to the other levels of integrated care by, for example, embedding education on the organisation of care (meso-level) or population-level prevention (macro-level) into their programme. Whether this is an essential element for learning about integrated care remains unclear. However, previous studies show that it is important for students to become acquainted with levels other than the micro-level in their education. For example, the 'framework of integrated competencies for adaptive expertise on integrated care' [57] describes that it is essential to know the patient and his or her care system and social system. Westerman et al. also emphasised that postgraduate medical education should address both the delivery of patient care and other factors, such as the finance and management side of healthcare [58]. In a study on education about integrated care for trainee paediatricians, in addition, trainees indicated that they felt it was important to learn about the whole of integrated care and learn to adapt to changes at the macro level [59]. Therefore, we suggest that education should not be limited to the micro-level of care.
Furthermore, our data imply that first-hand participation and experience contributed to learning how to deliver integrated care [34,37,41,42,46,[48][49][50][51][52]. These experiences should not be oversimplified [34,37,48,49,52]. The students' struggle with the reality of complex care for the elderly made them willing to provide patient-centred care and increased their understanding of integrated care. These programmes had in common that students experienced the complexity of care by putting themselves in the patients' position (e.g., through simulation) or were made responsible for the patients' comprehensive care. In addition, providing students with the authentic complexity of contemporary care contributed to learning to work cooperatively [51]. Rather than a simplified, so-called reductionist approach, complexity science reflects an approach in which the patient is considered as a complex system [60,61]. In this scientific movement, health care consists of different agents who interact in so-called Complex Adaptive Systems (CAS) [60]. These CAS succeed because their agents, rather than attempt to find a fixed solution, can adapt to changes in the system. This requires that students should gain adaptive expertise [57,62,63]. Sockalingam et al. argued that adaptive expertise could be meaningful in providing integrated care. They suggest that students would ideally first learn the scientific basis of diseases and their treatment before experiencing in practice or simulation how multimorbidity, the patient's context, and the doctor's preferences interact. This way, students would get the opportunity to experience care, struggle with it, and learn to adjust it in an integrated way, and thus learn about providing integrated care [63]. This aligns with a scoping review on educational programmes for collaborative care in psychiatry, in which the authors conclude that adaptive expertise is important to prepare students for addressing complexity [64]. Therefore, it seems essential for students to experience the complexity of healthcare. In this way, students could acquire the skills needed to deliver integrated care in the future.

STRENGTHS & LIMITATIONS
We would like to mention two strengths. Firstly, our diverse research team, consisting of educators, physicians, and a policy and management expert, allowed us to analyse the included papers from different perspectives. Secondly, we operationalised the WHO definitions of integrated care into ten components (Box 1), which made it possible to perform a broad search and identify the components of integrated care that the educational programmes addressed. Nevertheless, only 17 papers were electable, a limited number of papers that contrasts rather sharply with the global trend towards more integrated care. A lack of research publications does not necessarily mean that there is no education on integrated care. Nevertheless, this scoping review has exposed the limited extent of scientific knowledge and highlights the need for research regarding educational programmes on integrated care for the elderly.
A limitation is perhaps that we did not include grey literature. Because of the broadness of the concept of integrated care, searching with the same broad scope as in white literature would have led to an unworkable amount of information. A pilot search in grey literature only revealed programmes on integrated care in general, which did not address the elderly. Therefore, grey literature remained outside the scope of this review.
Another limitation could be the quality of the included papers. Some papers were very brief in describing their programmes and evaluations. Some evaluations were limited to stating that 'students enjoyed the programme' without clarifying what it was they enjoyed. Not all papers described the relevance of their educational programme, which made it challenging to understand the setting of the programme. The generalisability of the data, therefore, is limited. However, we believe that this review can be used as a source of inspiration and an incentive for developing education and research.

IMPLICATIONS FOR MEDICAL EDUCATION
The described educational programmes did not have integrated care as a primary learning objective but taught components of the WHO definition of integrated care. Therefore, this review does not provide evidence on the effectiveness of educational interventions on the full spectrum of integrated care. Nevertheless, this research shines a light on interventions for components of integrated care and can be used as an inspiration for developing education on this subject. In addition, we suggest promoting a broad scope in medical education on integrated care, by addressing, firstly, the broader meso-level and macro-level of integrated care and, secondly, by enabling students to experience the complexity of care. Furthermore, we suggest considering the challenges described: sufficient financial resources, location, the difference in students' levels of experience, teacher qualifications, enough time, and support from hospitals and educational institutions.

IMPLICATION FOR FUTURE RESEARCH
Future research should focus on descriptions of educational programmes that pay specific attention to a definition of integrated care to justify the choices made. It may be valuable to include information from educational programmes on integrated care that were outside the scope of this review, such as paediatrics or psychiatry. In addition, future research could examine what components of integrated care the educational programmes should address and why. Furthermore, most programmes focused on the micro-level of integrated care, and it remains unclear how the meso-and macrolevels of integrated care could be included. It would be a valuable addition, therefore, to investigate how these levels could be included in medical education.

CONCLUSION
Despite the global trend towards integrated care, none of the included articles aimed for integrated care as the main objective of their educational programme. They addressed only components of integrated care.
With this scoping review, we exposed the limited knowledge that is currently available and highlighted, moreover, the need for more research on educational programmes about integrated care for the elderly. The results suggest that exposing students to the various complexities and levels of integrated care could contribute to learning about providing integrated care. We also recommend educational programmes towards integrated care should pay attention to multidisciplinary collaboration, including social care. However, more research about integrated care in healthcare education is necessary.

APPENDIX
Appendix 1 Example of PubMed search string.